Multiple Choice Questions

Upper Limb Pathology

Please use the comments section at the bottom of the page if you have any query or feedback about any of the questions.

11. A glenoid profile radiograph (Slide) of a 21-year-old male rugby player with multiple traumatic anterior shoulder dislocations is presented.

Which of the following is the preferred treatment:

A) Sling for a period of 6 weeks
B) Physiotherapy emphasizing strengthening of dynamic shoulder stabilizers
C) Capsular shift
D) Bankart reconstruction
E) Coracoid transfer procedure

Correct Answer: E

The radiograph demonstrates anterior glenoid rim insufficiency, which is a risk factor for failure of soft tissue reconstructions especially in contact athletes. 

The arrows on the figure represent the anterior border of the glenoid rim. A coracoid transfer procedure to reconstruct the anterior bony deficiency maximizes the possibility for successful restoration of shoulder stability.

Author: Fouad Chaudhry

 

10. All of the following factors have been used to explain why exertional compartment syndrome is more common in the lower leg when compared to the upper arm except:

A) Muscle straining that occurs in the lower leg seldom occurs in the upper arm.
B) Muscle compartments of the upper arm blend anatomically with the shoulder girdle making it less likely that bleeding would be confined to the compartment of the upper extremity.
C) The brachialis fascia is less taut than the crural fascia.
D) The brachialis fascia yields more to increased intracompartmental pressure as compared to the crural fascia.
E) The pulse pressure of the lower extremity is greater than that of the upper extremity.

Correct Answer: A

Medial meniscal tears account for approximately 45% of acute tears and 70% of chronic tears in patients with ACL insufficiency. Peripheral posterior horn tears of the medial meniscus are the most common type of tear associated with chronic ACL deficiency.

Author: Fouad Chaudhry

 

9. A magnetic resonance image (MRI) of the dominant elbow of a 19-year-old minor league baseball pitcher is presented . He has been unable to pitch for the past 6 weeks secondary to pain. 

The recommended treatment includes:

A) Physical therapy for triceps strengthening 
B) Physical therapy for pronator strengthening 
C) Ulnar nerve transpostion 
D) Radial collateral ligament reconstruction 
E) Ulnar collateral ligament reconstruction 

Correct Answer: E

The MRI shows a disruption of the humeral attachment of the ulnar collateral ligament. The ulnar collateral ligament of the elbow is the most frequently observed ligamentous elbow injury in baseball pitchers. 

Recommended treatment in the throwing athlete is reconstruction of the ulnar collateral ligament with an autogenous palmaris longus graft

Author: Fouad Chaudhry

 

8. A “stinger” (transient weakness of the upper extremity commonly seen after a blow to the head and shoulder in football) most commonly affects the:

A) Spinal cord 
B) C-5/C-6 nerve roots 
C) C-7/C-8 nerve roots 
D) Axillary nerve 
E) Musculocutaneous nerve 

Correct Answer: B

"Stingers" are common in football. They generally result from a transient stretch to the C-5/C-6 nerve roots resulting in temporary loss of strength of the biceps, deltoid, and spinatus muscles.

It is generally safe to allow the athlete to return to participation, provided the cervical spine examination is normal and any neurological deficits have completely resolved. 

Author: Fouad Chaudhry

 

 

7.  A 55 -years-old man sustains an open fracture of the radius which was treated with open reduction and internal fixation. This operation was complicated with radial nerve injury which did not improve at follow up. 

Which of the following treatments will best restore function?

A)Transfer of pronator teres to extensor carpi radialis brevis
B)Transfer of deltoid to triceps
C)Transfer of the flexor carpi radialis to extensor digitorum and the palmaris longus to the extensor pollicis longus 
D)Transfer of pectoralis major to biceps
E)Transfer of common flexors tendon to the humerus

Best answer: C

 

For radial nerve palsy in the forearm palsy, the most beneficial transfers include transferring the flexor carpi radialis to the finger extensors (to restore finger extension) and palmaris longus to the extensor pollicis longus (to restore extension of the thumb).

In radial nerve palsy in the forearm, the patient has adequate wrist extension due to intact ECRL (providing radial wrist extension) supplied by the radial nerve proximal to the elbow.
Transfer of pronator teres to extensor carpi radialis brevis,and Transfer of deltoid to triceps are indicated in radial nerve palsy .

Transfer of pectoralis major to biceps and transfer of common flexors tendon to the humerus are both indicted in musculocutaneous nerve palsy. 

Ref: Ropars M, Dréano T, Siret P, Belot N, Langlais F. Long-term results of tendon transfers in radial and posterior interosseous nerve paralysis. J Hand Surg Br. 2006 Oct; 31(5):502-6.

Author :Firas Arnaout

 

6.  A 45 years old plasterer complains of long standing pain over the lateral aspect of the elbow. The pain worsens when using a brush. On examination, the symptoms are exacerbated with resisted wrist extension while the elbow is fully extended. 

Which muscle is likely to be involved?

A) Anconeus
B) Brachioradialis
C) Extensor carpi radialis brevis
D)Flexor carpi radialis
E) Supinator

Best answer: C

 

This clinical presentation is consistent with lateral epicondylitis (tennis elbow), which is caused from inflammation and tendonitis at the origin of the extensor carpi radialis brevis (ECRB).

It is common with repetitive activities of supination and pronation with elbow in extension

Clinical examination findings include tenderness over the insertion of theECRB, and pain that is reproduced with gripping, resisted long finger extension (ECRB inserts on the base of 3rd metacarpal), resisted wrist extension while the elbow is fully extended.

It is treated with activity modification, physiotherapy and steroid injections; surgery is indicated if nonoperative measures fail.

Ref: Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. 1979 Sep;
61(6A):832-9

Author :Firas Arnaout

 

5.  Which anatomical structure provides the primary dynamic stability and restraint to the shoulder and keeps the humerus head centred on the glenoid?

A) Glenohumeral ligaments
B) Deltoid muscle
C) Rotator cuff muscles
D)Biceps muscle tendons
E) Glenoid labrum

Best answer: C

The rotator cuff is the main dynamic stabilizer of the glenohumeral joint. The rotator cuff muscles are: supraspinatus, infraspinatus, teres minor and subscapularis

The glenohumeral ligaments (superior, middle and inferior), the glenoid labrum (increases the depth of the labrum) and the shoulder joint capsule are static stabilizers;

The biceps is a secondary dynamic stabilizer.

 Ref: Netter's Concise Atlas of Orthopaedic Anatomy, Frank H. Netter, John A. Craig.

 Author :Firas Arnaout

 

4. In shoulder examination, which test is used to diagnose subacromial impingement?

A) Obrien test
B) Apprehension test
C) Cross body adduction (scarf) test
D) Speed test
E) Job test

Best answer: E

Job test is used for subacromial impingement. Performed by abduction of the shoulder to 90 degrees in the scapular plane, and internally rotate the shoulder so that the thumb is pointing down. Then press down with patient attempting to resist, the test is positive if there is pain.

Obrien test is for labral injuries, apprehension test is for instability, scarf test is for acromioclavicular joint and speed test for biceps injuries.

Ref: Review of Orthopaedics, 5th Edition, Mark D. Miller (editor), Saunders, an imprint of Elsevier, Philadelphia, Copyright 2008.Page 272.

Author :Firas Arnaout

 

3.  The glenohumeral joint relies on static and dynamic stabilizers to remain centred. Which structure is the main dynamic stabilizer of the shoulder joint?

A) The glenoid labrum
B) The capsule
C) The glenohumeral ligaments
D) The negative intraarticular pressure
E) The rotator cuff muscles

Best answer: E

The glenohumeral joint is the most mobile joint in the body. All the above structures are static stabilizers, except the rotator cuff which is a dynamic stabilizer. It is innervated by C5 and C6.

The rotator cuff consists of the subscapularis anteriorly, supraspinatous superiorly, infraspinatus and teres minor posteriorly

 Banaszkiewicz & Kader.postgraduate orthopaedics, 2nd edition, 2012, page 151

 

Author :Firas Arnaout

 

2.  The anterior interosseous nerve innervate all of the following except:

A) The pronator quadratus
B) The abductor pollicis longus
C) The flexor pollicis longus
D) The radial half of the flexor digitorum profundus                                                                                                                                                  
E) Wriste capsule

Best answer: B

 

The abductor pollicis longus is innervated by the posterior interosseous nerve.

 

1.  The trigger finger is:

A) Inflamed index finger
B) Atrophic index finger in a median nerve palsy
C) Essential feature of the carpal tunnel syndrome
D) Result of stenosing tenovaginitis affecting one of the flexor tendons in the palm                                                                     
E) caused by stenosing tenosynovitis at the A2 Pulley

Best Answer : D

Author Dr. Zeeshan Siddique

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